Process of developing models of maternal nutrition interventions integrated into antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India

Abstract Integrating nutrition interventions into antenatal care (ANC) requires adapting global recommendations to fit existing health systems and local contexts, but the evidence is limited on the process of tailoring nutrition interventions for health programmes. We developed and integrated maternal nutrition interventions into ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India by conducting studies and assessments, developing new tools and processes and field testing integrated programme models. This paper elucidates how we used information and data to contextualize a package of globally recommended maternal nutrition interventions (micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding) and describes four country‐specific health service delivery models. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during ANC. We used multiple information sources including situational assessments, formative research, piloting and pretesting results, supply assessments, stakeholder meetings, household and service provider surveys and monitoring data to design models of maternal nutrition interventions. We developed detailed protocols for implementing maternal nutrition interventions; reinforced staff capacity, nutrition counselling, monitoring systems and community engagement processes; and addressed micronutrient supplement supply bottlenecks. Community‐level activities were essential for complementing facility‐based services. Routine monitoring data, rapid assessments and information from intensified supervision were important during the early stages of implementation to improve the feasibility and scalability of models. The lessons from addressing maternal nutrition in ANC may serve as a guide for tackling missed opportunities for nutrition within health services in other contexts.


| INTRODUCTION
According to the Global Burden of Disease analysis, there were 135.3 million live births and many more pregnancies in 2019 (GBD Demographics Collaborators, 2020). The outcomes of these pregnancies are substantially related to the nutritional status of mothers during and before pregnancy. Poor maternal nutrition is associated with increased risks of maternal morbidity and higher risks of foetal losses, preterm delivery, growth restriction, stunting and cognitive impairment (Ramakrishnan et al., 2012;Victora et al., 2021). The World Health Organization (WHO) emphasized the importance of addressing maternal undernutrition to accelerate progress in achieving global nutrition targets and Sustainable Development Goals for stunting, anaemia in women, low birthweight and wasting (Christian et al., 2013;WHO, 2021).
During pregnancy, women need to consume adequate energy and good quality protein, carbohydrates, fats, vitamins and minerals (IOM, 2009;Kominiarek & Rajan, 2016). Yet, maternal diets in many low-and middle-income countries (LMICs) are suboptimal with imbalanced macronutrient intakes and inadequate micronutrient content . To overcome these challenges, various interventions have been suggested including counselling on the use of nutrient-rich, locally available foods and food and nutrient supplementation (e.g., iron folic acid [IFA], calcium and multiple micronutrients) and weight gain monitoring to maintain healthy weight gain by adjusting food intakes to prevent undernutrition or overweight and obesity (WHO, 2016). Antenatal care (ANC) guidelines published by WHO (2016) highlighted the importance of integrating evidence-based nutrition interventions. WHO also recommends the preparation of pregnant women (PW) and their family members by ANC providers to place the baby on their chest immediately after delivery, not feeding the baby anything other than colostrum or breast milk and counselling on critical skills to initiate breastfeeding (WHO, 2018).
ANC is one of the most widely used health services and provides an important opportunity to reach PW with a package of nutrition interventions (Heidkamp et al., 2021;Shekar et al., 2021). A study using representative data from 81 LMICs found that high-quality, evidencebased, health interventions delivered to mothers and their newborns who are already seeking care would lower maternal deaths by an estimated 28%, neonatal deaths by 28% and stillbirths by 22%, as compared with a scenario without improvement in quality of care (Chou et al., 2019).
Despite the WHO recommendations and evidence, large gaps exist and too many PW who attend ANC do not receive nutrition interventions (Heidkamp et al., 2020;Kavle & Landry, 2018).
Integrating globally recommended maternal nutrition interventions (MNIs) into existing large-scale ANC programmes requires systematic adaptation to ensure relevance and feasibility (Barreix et al., 2020). High-quality service delivery requires fitfor-purpose tools and skills and motivation of ANC providers and community health workers to apply them. Supportive care provided to PW is needed to enable the adoption of recommended nutrition practices. However, there is no documented experience on how to adapt a package of multiple MNIs for integration into ANC. This paper aimed to: (1) elucidate how information and data were used to contextualize a package of MNIs, specifically micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding, for integration into existing ANC services; and (2) describe country-specific programme models of maternal nutrition services delivered through large-scale ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India. The MNIs were designed and supported by Alive & Thrive (A&T), an initiative that supports the scaling up of nutrition interventions to save lives, prevent illnesses and contribute to healthy growth and development through improved maternal and infant and young child nutrition practices in several African and Asian countries.

| METHODS
We worked in four countries (Bangladesh, Burkina Faso, Ethiopia and India) alongside government and other stakeholders to design and implement a package of globally recommended MNIs (WHO, 2016) through existing large-scale ANC programmes. The MNIs include micronutrient supplementation (IFA and calcium distribution and counselling), weight gain monitoring (measurement and counselling), dietary counselling (on meal frequency, food amounts and dietary diversity) and counselling on breastfeeding (early initiation [EIBF] and exclusive breastfeeding [EBF)]. In each country, we incorporated global recommendations into programme protocols, reinforced system readiness to implement the protocols through well-defined tasks and staff skills, developed and disseminated training tools and job aids, identified gaps, improved equipment/supply chain specifications and strengthened record-keeping and data-use protocols.

Key messages
• Integrating evidence-based nutrition interventions into ANC to reach PW at scale is urgently needed for improving maternal and newborn health and nutrition.
• The Theory of Change and steps for strengthening nutrition interventions based on four-country experiences provide practical guidance on addressing missed opportunities for nutrition in ANC.
• Strategic use of data can contextualize global maternal nutrition guidelines, protocols, capacity building and supervision approaches, and improve micronutrient supply chains and record-keeping as part of health services strengthening.
• Engaging family and community members to support PW and improving the knowledge and self-confidence of PW are important elements of all country programme models.
The duration of intervention planning, development and implementation varied between 3 and 4 years per country, starting in 2014 until ending in 2021 ( Figure 1). Programmes in Bangladesh and India were completed in 2016 and in early 2020, respectively, and thus were not affected by the COVID-19 pandemic. Implementation in Burkina Faso and Ethiopia ended in 2021, and utilization of ANC and other nutrition services decreased temporarily in mid-2020 due to COVID-19 restrictions. Several adaptations were applied to maintain and restore services during the pandemic in these countries. Country teams (including the Ministry of Health staff responsible for ANC and nutrition units, community workers and volunteers, national nongovernmental organizations (NGOs), academic institutions, research institutes and A&T staff) were involved in different aspects of design, implementation and assessments. In 2020 and 2021, we compiled our programme implementation documents, protocols and tools to extract information on steps taken to tailor the interventions and strategies to country contexts and to describe each country's model.
First, an overarching Theory of Change that illustrates the country's programme needs was developed to describe common barriers and strategies, expected outcomes and health and nutrition impacts ( Figure 2). The Theory of Change was derived from desktop reviews of the literature, situational assessments, special studies and midline assessments, formative studies and surveys conducted by collaborators in the four countries. Strategies for delivering nutrition interventions through ANC were shaped by WHO's recommendations (WHO, 2016), WHO health systems building blocks (WHO, 2007) and the socioecological model of social and behaviour change applied previously by A&T (Sanghvi et al., 2016).
Data and information were used before, during and after the interventions were launched to continuously find gaps and modify the country programme models. In the early stages of implementation, the data and information sources included (1) situational analyses (assessment of policy and protocol gaps and the strengths and weaknesses in ANC service platforms), qualitative research (on perceptions and motivations of PW, family members and community members) and stakeholder workshops convened by government authorities and A&T to discuss policies, feasible protocol modifications, task allocation and engagement of other sectors (such as relevant ministries, local governments and religious institutions); (2) field testing of processes and tools designed to strengthen nutrition interventions; (3) assessments of micronutrient supplement supply chains; (4) baseline surveys with PW and recently delivered women (RDW) as well as their family members, health providers and community health workers. Codesigning workshops were held with ANC service decision-makers, supervisors and managers, ANC providers, members of local health and development NGOs, village leaders, local government authorities, health volunteers and family members of PW.
During the workshops, roles and responsibilities of actors were identified and tasks were allocated where needed. These workshops provided a reality check for the extent to which ANC providers could undertake additional tasks related to MNIs and helped to build ownership among health managers, service providers and community members who were represented in the process. In Ethiopia and India, we used data from F I G U R E 1 Overview of timeline and main data sources to adapt maternal nutrition interventions for integration into ANCs. ANC, antenatal care; Ca, calcium supplements; FR, formative research; IFA, iron and folic acid supplements; MNIs, package of maternal nutrition interventions.  Schuler, 2015). Structured surveys of PW, RDW, ANC providers and community workers were conducted to generate baseline data for impact evaluation and informed the programme designs (Kim, Ouédraogo, et al., 2020;Nguyen et al., 2015Nguyen et al., , 2018. Multivariable analysis in Bangladesh and India Nguyen et al., 2019) helped us to prioritize factors associated with maternal nutrition practices, while qualitative research in all countries provided additional insights into motivations, barriers and influential persons as well as the readiness of PW to adopt recommended practices.
During implementation, we used different data collection strategies based on programme needs and available resources. In Bangladesh, we conducted rapid household assessments over a 6-month period and service record reviews in selected areas on a limited number of topics to track coverage and practices associated with new processes; this involved using two-to three-page checklists to complement routine monitoring to determine if certain modifications made during implementation were working. In Burkina Faso, we conducted two rounds of exit interviews with ANC users, and in Ethiopia, we carried out a mid-line service provision assessment including observations and exit interviews. In India, we conducted several studies such as the cost of diets to determine the feasibility of dietary recommendations  and progress in intervention coverage . The types of data and information sources are listed in Table 1.
We identified gaps and opportunities through different sources of data and information and used the findings to develop locally relevant interventions. During implementation, bottlenecks that were not anticipated in the design phase were identified and rapidly addressed through supervision and monitoring. When new issues were identified, strategies were continuously adjusted. Each country used existing mechanisms and resources available for tracking progress and detecting needs such as gaps in supplies, lack of counselling, or incorrect use of ANC registers and information, education and communication materials.
Frequent meetings with providers and authorities responsible for ANC services were important for triangulating information to arrive at decisions on how to refine the interventions. We refined the programme models throughout implementation with the goal of improving effectiveness, feasibility and scalability of approaches designed to strengthen the quality of nutrition services and adoption of nutrition practices. Four country-specific models of nutrition integrated into ANC were finally developed.

| Ethical considerations
Ethical approval for all research studies was obtained from the Institutional Review Boards of the designated countries and from the International Food Policy Research Institute.

| RESULTS
The main steps applied for adaptation and integration and data sources for developing the MNIs in each country are presented in Table 1. The final MNI protocols that resulted from this process are shown in Table 2. For each MNI, we summarized the lessons learned for operationalizing these protocols in the context of existing ANC programmes ( Table 3). The integrated models reflect global recommendations, national policies and country-specific patterns of ANC service delivery such as ANC locations, types and frequency of F I G U R E 2 Theory of change 1 for strengthening maternal nutrition interventions 2 in antenatal care services.
T A B L E 1 Steps and data sources to adapt maternal nutrition interventions for integration into ANC services in Bangladesh, Burkina Faso, Ethiopia and India Steps -ANC provider and health volunteers (n = 300) -Survey of husbands of RDW (n = 1400) (Nguyen et al., 2015 -Routine monitoring by providers, for example,  -Compilation of existing formative research (Clemmons & Griffiths, 2016) -Dialogue with two regional governments and national staff -Codesign workshops to contextualize the programme for two regions -Pretesting tools and materials, pilot tests -h IFA supplement supply system reviewed at facilities, regional hubs and teams at the national level -Surveys of RDW women (n = 344), PW (n = 175 -Survey of ANC providers (n = 120)  -

| Content of MNIs
The four MNIs existed in principle at the national policy level in all the countries with a few gaps (e.g., calcium supplementation was not included in ANC in Burkina Faso and Ethiopia). However, ANC in all countries had missing elements in MNI protocols and did not adequately specify nutrition-related tasks for facility-based and community-level service delivery, supervision and monitoring . Although IFA supplementation was better addressed than the other nutrition interventions, knowledge gaps related to all MNIs were observed among ANC providers and PW.
The adherence of PW to recommended nutrition practices was low (Kim, Ouédraogo, et al., 2020;Nguyen et al., 2015Nguyen et al., , 2018. Inadequate understanding of MNIs and poor skills in counselling among providers were common . We developed tools for strengthening counselling quality with specific content for each MNI based on global recommendations. Faso and India adopted one daily tablet to be consumed for 6 months of pregnancy (a total of 180 IFA tablets), as globally recommended.
Ethiopia recommended 'at least 90 IFA tablets', which was the cutoff used as a coverage indicator in national surveys. Supplements were distributed free of cost in all ANC services. In Bangladesh and India, calcium supplementation was also included in the ANC guidelines (Nguyen et al., 2015(Nguyen et al., , 2018

| Supports and inputs to strengthen service delivery
To enable the delivery of effective MNIs integrated into ANC, we needed to address underlying barriers such as delayed and infrequent ANC visits, low capacity of health personnel in maternal nutrition service delivery, weak linkages with families of PW and lack of emphasis on strengthening PW's self-efficacy. Steps taken to address these barriers included facilitating early initiation of and more frequent ANC contacts, building the nutrition capacity of managers and ANC providers to deliver MNIs, strengthening family and community engagement to support PW and building the knowledge and self-confidence of PW to adopt the recommended nutrition practices (

| Country programme models developed by A&T
The Bangladesh model was based on a nationally scaled-up maternal nutrition and child health programme that was being implemented by an NGO (BRAC) to extend essential services to communities. BRAC's integrated ANC programme used a performance improvement cycle to build service provision capacity through task allocation, ongoing training, job aids, supervision and monitoring feedback, and performance-based cash incentives for community volunteers.
Husbands' forums were structured so that each husband would attend the forums at least twice during their wife's pregnancy. The ANC service platform with high coverage and frequent contacts with PW was strengthened further with additional nutrition service content, which significantly improved IFA and calcium adherence, weight gain tracking, dietary diversity and EBF practices .  (Kim, Ouédraogo, et al., 2020;Kim, Rock, et al., 2021). With additional training and support to build government health system capacity by integrating MNIs into ANC services at the facility and community levels, the model led to significant improvements in early initiation of and frequency of ANC contacts, IFA adherence and early breastfeeding practices (Kim, Rock, et al., 2021).
The Ethiopia model was tailored to two distinctly different regions -Somali (pastoralist region) and SNNP (Southern Nations, Nationalities and Peoples, agrarian region). Both regional versions of the country programme models focussed on improving MNIs integrated into ANC services in primary health care centres and local health posts of the government health system. Capacity building of health centre staff and health extension workers for service delivery to PW was a priority in both regions; existing community activities such as group education and home visits were used as channels for reinforcing key MNI messages. Training and orientation sessions and ongoing coaching to government staff for continued adaptation of the service provision and community activities by partner NGOs familiar with each region led to improved coverage of MNIs, dietary diversity and IFA adherence .  .

| DISCUSSION
In our paper, we provide examples of how four country models were developed to integrate and enhance MNIs into ANC services. We describe lessons learned from developing the models through a systematic process to contextualize a package of nutrition interventions. Our findings demonstrate the importance of combined facilityand community-based approaches to improve service provision and adoption of recommended maternal nutrition practices.
Our findings were similar to experiences from other initiatives for incorporating global recommendations within national health services. Designated periods of field implementation and adjustment were necessary to increase the relevance and acceptability of interventions in large-scale programmes (Fischer et al., 2016). The Integrated Management of Childhood Illnesses initiative (Lambrechts et al., 1999) and country applications of WHO's ANC guidelines (Barreix et al., 2020) were guided by country priorities and national regulations and policies and were then thoroughly tested for the feasibility of service delivery through the health system. Our approach was also similar to that of the Saving Newborn Lives initiative (Tinker et al., 2010)  This study contributes to reducing missed opportunities in delivering nutrition interventions in health services (Heidkamp et al., 2020;Shekar et al., 2021) by providing detailed insights on how we integrated MNIs in four large-scale ANC services. WHO narrowed the gap between maternal nutrition research and health service practices by providing a synthesis of evidence and guidelines (WHO, 2016(WHO, , 2017. However, the presence of recommendations and programme platforms for service provision does not assure their adoption. Upfront investments were key for learning how to adapt and integrate the MNIs within existing services by understanding the strengths and challenges in ANC provider performance, programme platforms that reach PW and opportunities to leverage community networks to support ANC service use and nutrition practices. Our experience provides insights into a systematic process for integrating MNIs into ANC in diverse settings. In summary of our numerous lessons learned, we provide the following 10 steps: (1) review current policies and protocols; (2) synthesize findings from formative research and other data analyses to identify key areas of intervention; (3) identify service delivery gaps by assessing existing approaches that relate to the delivery of nutrition interventions in ANC; (4) document the gaps specifically in tasks and staff skills for implementing MNIs; (5) assess the adequacy of current frequency, coverage and quality of training and related tools and job aids; (6) review the need for improved equipment/supply chain and record keeping protocols; (7) document the current use of data to monitor delivery of MNIs and how monitoring data are used to improve the coverage and quality of MNIs; (8) identify the existing community and family linkages to improve ANC service use specifically for MNIs; (9) share the above findings with stakeholders from the health system, academic institutions and the communities; (10) organize codesign workshops to discuss findings, fill in critical gaps in background information, develop feasible processes for improving MNIs in ANC and build joint ownership.
A unique aspect of this paper is the focus on scalability. Working on models for large-scale programmes required greater attention to system-wide improvements rather than focusing on health facilities and communities alone. To help transfer our lessons learned to other countries, the theory of change illustrates the barriers commonly faced in LMICs when attempting to strengthen nutrition interventions delivered through ANC on a large scale. We provide examples of lessons learned and innovations developed in our country's programmes to implement the strategies listed in the ToC.

| CONCLUSIONS
The evidence on maternal nutrition's foundational role in determining lifelong and intergenerational health and productivity has been growing (Victora et al., 2021). Nutrition was one of five content areas recommended globally for integration into ANC services (WHO, 2016).

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available in the tables/figures and in the Supplementary Information of this article.